I’d like to ask a question to all of you medical-type folks out there, and for this one I’d like other healthcare professionals to weigh in, not just EMS. Of course, Paramedics and EMTs are encouraged to answer this question, but so are Physicians and Nurses (RN and LPNs), as well as CNAs and Techs.

A conversation I had on Twitter regarding administration of 10% Dextrose IV (D-10) as opposed to 50% Dextrose IV (D-50) for hypoglycemic ambulance patients has me wondering something about how we paramedics can create major savings and improve patient care in a short amount of time. We need to look for more “Low Hanging Fruit”.

It is common practice for known diabetic patients presenting with low blood sugar (hypoglycemia) to receive a treatment with IV D-50, IM Glucagon, oral Glucose, or even with the “Kaiser Cocktail” and then sign off with an AMA refusal. The patients are encouraged to eat something containing protein and complex carbohydrates and are usually left in the care of one of their family members and/or friends who can watch them for a while and make sure they’re ok.

I’d say that calls like this make up a fairly large percentage of all calls for an ambulance. While I have no statistics to back me up, I would guess that it could be something like 5% or better. This complaint and resultant treatment pathway is something I do quite frequently in my own practice. Judging from my own experience, I would say it happens quite frequently in most other paramedics’ practices as well.

The question about administering D-10, as brought up by my twitter peep @un_ojo, is if all patients getting treatment with D-10 as opposed to D-50 should be transported to an Emergency Room. My answer was that I believe a 100% transport policy in this case would result in a lot of people being transported to an ER when they probably didn’t really need to be. This would result in a large population of non-emergent ambulance patients going to the ER who in the past would have been “treated and released” (at least under the guise of an AMA refusal) by EMS crews.

And that got me thinking about this question:

If paramedics did not currently have the means to treat hypoglycemia and every one of those patients were being transported to the ER, how much of a burden on the emergency healthcare system would be removed simply by giving paramedics D-50? Probably quite a bit, right?

What other common medical cases would be as appropriate for field “treat and release” (or “Treat and AMA”) care by EMS? If we save a few hundred trips to the ER by being able to sweeten-up and then release common hypoglycemics, what other conditions might we be doing the same for as safely and effectively?

Would this require some easily attainable training? What about new medications and/or equipment?

I look at this as the “Low Hanging Fruit” if you will, of EMS 2.0, and also of healthcare reform. I am a proponent of EMS crews handling more primary care duties, or failing that, of at least having more options in regards to treatment pathways.

That’s what I’m looking for here, folks. What could we do within six months that would make a big impact?

It can be as simple and stupid as the IV set you're using. Too many providers around here (especially the departments that pre-spike their bags) use whatever IV set their fingers touch first. Then, often they transport to a hospital that uses a completely different set.

Since we restock from the hospital, the IV set that is used by Hospital A ends up on the top of the pile in the cabinet, and on the next transport, to Hospital B, the bag is spiked with Hospital A's drip set.

So what happens at Hospital B?

The entire IV set, bag and all, is thrown out- ESPECIALLY if Hospital B uses a needless set and Hospital A doesn't. JCHAO requires any drip be on a pump- even a saline drip if the rate setting is important- and the drip sets are sold to the hospitals by the companies which sold them their IV pumps- and wouldn't you know it, only Acme IV tubing fits Acme pumps.

Since most of these EMS IV lines are KVO at best, and the busiest departments are the ones with the shortest transport times, we have dozens and dozens of IV bags- many with barely 100cc of fluid used- being trashed on a daily basis.

Dozens of sets, every day, multiplied by thousands of hospitals across the country…..

It sounds like a stupid thing to worry about or pay attention to. But I'm willing to bet it represents millions of dollars. Possibly many millions.

At my last job, where on any given day I could transport to half a dozen different hospitals, I took pains to make sure I had at least one drip set- and even their individual locks- from each hospital on my truck. It makes the nurse's job easier, which helps them remember you (in a positive way), and saves money.

Ambulance_Driver

Carry only the minimum set of IV fluids – a few bags of saline and a couple of 250 ml bags of D5W or D10W, and use mostly saline locks. Very few of the IVs we start in the field are used to administer fluids or medications in the hospital.

And develop spinal clearance protocols with TEETH. None of this “mechanism of injury” criteria crap. It's not reliable. How many patients do we needlessly board and collar, and how many needless C-spine films are done, based on little more than superstition and fear of litigation?

Of course, that second one will be a little harder to implement. Even the ERs don't use NEXUS criteria as it was designed to be used – as a way to rule out unnecessary x-rays. Instead, it's just the criteria they use to quickly remove our immobilization equipment. They still get the pointless x-ray anyway.

Sorry it took so long for me to get around to comment on this. Time flies when your buried by shift bids, closing hospitals, and non-compliant CSS.

I think that one of the major low hanging fruits are those under the influence of alcohol. It is extremely rare, at least in the city, for anyone to spend time in the LE “Drunk Tank”. This is because they get sent to the hospital via ambulance, where they tie up a bed, receive a potassium enriched IV, and are released the next morning after a Yule time feast of green eggs and red jello.

Of course, there are those who will point out that those under the influence have a tendency to acutely bang their heads which could lead to a cerebral hemorrhage and eventual death which is separate from the liver failure induced by chronic abuse which, by the way, will also eventually lead to death. To those who would hold those few as a reason to over treat so many, I would have to say that at some point people need to accept responsibility for their own actions.

If we're going to continue getting called out for those who enjoy the spirits, then at least let them RMA/AMA if they want irregardless of what we assume their mental capacity SHOULD be as opposed to what it ACTUALLY is.

At least, that's what I would strive for.

Tj Edwards

Have you seen the Welsh study that recommends the use of 10% dextrose? The research demonstrates a more stable diabetic after administration of this treatment that 50%. That’s less time in hospital and a much healthier patient, meaning less calls. Less calls is the real aim of the game, not cheaper treatment.

One thing I noticed was how many times I’ve had to transport patients to the hospital for less than 5 minutes for a Foley Catheter placement. In Iowa it was required as part of my Paramedic program. And even before that as an Army Medic I learned how to do it during my Medic school. Now, here in Wisconsin, it isn’t even touched upon. How much money would it save to allow a crew to show up and place a Foley in the 450lbs Vent Dependent patient versus transporting that same patient using a critical care crew w/vent, bariatric cot, and assist crew? All because the nurse at the nursing home couldn’t get it, or ran out? We already do the same thing with IV starts. It reaches back to the problem with inconsistent education standards across the entire profession.

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